Healthcare Provider Details

I. General information

NPI: 1821105362
Provider Name (Legal Business Name): RODERICK W KRUEGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54308-8900
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-4560
  • Fax:
Mailing address:
  • Phone: 414-647-6326
  • Fax: 414-671-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22893
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22785
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: